LAB25R-TRAIN-001-appB1.docx

Appendix D

PHASE I PROPOSAL SUBMISSION TEMPLATE &

REQUIRED TEMPLATE ATTACHMENTS

A. General Proposal Information

1. Name and Address of Lead Applicant Organization

(Contract Signatory/Email: if different than contact person)

County (ies) this program will serve?

|_| New Castle County |_| Kent County |_| Sussex County |_| Statewide

UEI (Formerly DUNS) #:

EIN ID #:

2. Lead Organization Type:

|_| Non Profit |_| Governmental |_| Private for Profit

3. Targeted Industry:____________________________

OR

Targeted Common Skill(s): _______________________________________________________________

4. Project Name:___________________________________________________

5. Required Partners Employer Partner 1:______________________ (if same as Lead enter “Lead Applicant”)

Employer Partner 2:______________________

Additional Employers: ________________________________________________________________________

Other Stakeholder 1:____________________________

Additional Stakeholder: ________________________________________________________________________

6. Funding:

Total Amount Requested: $_____________

Requested funds for this program are % of organization's total budget.

Leveraged Resources Provided if any:

· Cash Contribution Amount:__________________

· In-Kind Amount:__________________ These leveraged funds will support the following: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. Describe the manner in which you propose to meet the Planning Phase I goals and develop a Strategic Workforce Training Plan (should answer questions; who, what, when, where, why, how) – no page limit

Activity Schedule

Please enter a proposed schedule of activities that will take place and an estimated date they will occur. All dates should be within the performance period. You may add or delete rows as needed.

Achieved

Budget Summary

Organization:__________________________

Staff Salaries:

Staff Fringe Benefits:

SUBTOTAL

Supportive Services to Participants:

Rent:

Custodial Services:

Utilities:

Consumable Office Supplies:

Postage:

Equipment and Furniture Purchases (please include as an additional page what you plan to purchase)

Equipment Rental (please include as an additional page what you plan to rent)

Tuition:

Entrance Fees:

Training Materials:

Printing/Advertising:

Staff Travel:

Student Travel (this does not include gas cards/bus tokens)

Staff Training:

Participant Wages:

Participant Fringe:

Insurance:

Professional Services (Specify on separate page)

Overhead/Indirect for Parent Organization

Profit:

Other:

Total:

Certificate of Information and Authorization-Must be completed for your proposal to be considered.

By submitting this proposal, I hereby certify that to the best of my knowledge all information contained in this proposal is accurate and complete, that this is a valid proposal and that I am legally authorized to submit and to represent this organization.

Signature (live):______________________________________________________

Name:______________________________________________________________

Title:_______________________________________________________________

Organization:________________________________________________________

D. Attachments-Required except unless noted Attachment 1: Non-Collusion Statement Attachment 2: Exceptions Attachment 3: Confidentiality and Proprietary Information Attachment 4: Business References Attachment 5: Subcontractor Information Form (only if applicable)

Attachment 1

RFP NO.:

RFP TITLE:

DEADLINE TO RESPOND:

NON-COLLUSION STATEMENT

This is to certify that the undersigned Provider has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this proposal, and further certifies that it is not a sub-contractor to another Provider who also submitted a proposal as a primary Provider in response to this solicitation submitted this date to the State of Delaware, Workforce Development Board.

It is agreed by the undersigned Provider that the signed delivery of this bid represents, subject to any express exceptions set forth at Attachment 2, the Provider’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions.

NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Workforce Development Board.

Corporation

Partnership

Individual

COMPANY NAME ________________________________________Check one)

NAME OF AUTHORIZED REPRESENTATIVE

(Please type or print)

SIGNATURE TITLE

COMPANY ADDRESS

PHONE NUMBER FAX NUMBER

COMPANY CLASSIFICATIONS:

CERT. NO.: __________________

[The above table is for informational and statistical use only.]

PURCHASE ORDERS SHOULD BE SENT TO:

ADDRESS

CONTACT

PHONE NUMBER FAX NUMBER

EMAIL ADDRESS

AFFIRMATION: Within the past five years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment?

YES NO if yes, please explain

THIS PAGE SHALL HAVE ORIGINAL SIGNATURE AND BE RETURNED WITH YOUR PROPOSAL

SWORN TO AND SUBSCRIBED BEFORE ME this ________ day of , 20 __________

Notary Public My commission expires

City of County of State of

Attachment 2

RFP NO.:

RFP TITLE:

EXCEPTION FORM

Proposals must include all exceptions to the specifications, terms or conditions contained in this RFP. If the provider is submitting the proposal without exceptions, please state so below. The State of Delaware reserves the right to deny any and all exceptions taken to the RFP requirements.

|_| By checking this box, the Provider acknowledges that they take no exceptions to the specifications, terms or conditions found in this RFP.

Proposed Alternative

Note: Provider may use additional pages as necessary, but the format shall be the same as provided above.

Attachment 3

RFP NO.:

RFP TITLE:

CONFIDENTIAL INFORMATION FORM

|_| By checking this box, the Provider acknowledges that they are not providing any information they declare to be confidential or proprietary for the purpose of production under 29 Del. C. ch. 100, Delaware Freedom of Information Act.

Confidentiality and Proprietary Information

Note: Provider may use additional pages as necessary, but the format shall be the same as provided above.

Attachment 4

RFP NO.:

RFP TITLE:

BUSINESS REFERENCES

List a minimum of three business references, including the following information:

· Business Name and Mailing address

· Contact Name and phone number

· Number of years doing business with

· Type of work performed Please do not list any State Employee as a business reference. If you have held a State contract within the last 5 years, please provide a separate list of the contract(s).

Business Name:

Address:

Email:

Phone # / Fax #:

Current Provider (YES or NO):

Years Associated & Type of Work Performed:

Business Name:

Address:

Email:

Phone # / Fax #:

Current Provider (YES or NO):

Years Associated & Type of Work Performed:

Business Name:

Address:

Email:

Phone # / Fax #:

Current Provider (YES or NO):

Years Associated & Type of Work Performed:

STATE OF DELAWARE PERSONNEL MAY NOT BE USED AS REFERENCES.

Attachment 5

SUBCONTRACTOR INFORMATION FORM

PART I – STATEMENT BY PROPOSING PROVIDER

1. RFP NO.

LAB 18 001-ADULTTRNG

2. Proposing Provider Name:

3. Mailing Address

4. SUBCONTRACTOR

a. NAME

4c. Company OSD Classification:

Certification Number: _____________________

b. Mailing Address:

4d. Women Business Enterprise |_| Yes |_| No 4e. Minority Business Enterprise |_| Yes |_| No 4f. Disadvantaged Business Enterprise |_| Yes |_| No 4g. Veteran Owned Business Enterprise |_| Yes |_| No 4h. Service Disabled Veteran Owned Business Enterprise |_| Yes |_| No

5. DESCRIPTION OF WORK BY SUBCONTRACTOR

6a. NAME OF PERSON SIGNING

6b. TITLE OF PERSON SIGNING

PART II – ACKNOWLEDGEMENT BY SUBCONTRACTOR

9a. NAME OF PERSON SIGNING

9b. TITLE OF PERSON SIGNING

* Use a separate form for each subcontractor